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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 2,11'1v A-✓r-D e--151yi7=� Gr2tu.-PERMIT SR <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect.. <br /> License #: 0 b Exp Date: <br /> Date: <br /> Contractor:l� 0/ <br /> Signature: <br /> Title: s�l4.J_���kr57 <br /> Print Name: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance,as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: / <br /> Carrier: _C`t�� Sw�?� Policy Number: 71 3155 5S 3 7 D K <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisi <br /> 2 / y nature: <br /> Exp. Date: Si� / / 9 ( — <br /> Print Name: \ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLSUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I fes'niL`^— ignature of C-57 licensed authorized representative), <br /> to <br /> hereb orize (print name) <br /> ( <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> sr29ro2/MI <br /> WELL PERMI1 APP <br /> EH029-01 M5:071 <br />